Lecture No.11
Policy Brief Writing and Global Health

Nirmala BHOO-PATHY is a public health physician and epidemiologist with a distinguished career dedicated to advancing cancer care systems and improving life after cancer. Her research and policy advocacy support evidence-based strategies to bridge critical gaps in cancer care, particularly across low- and middle-income countries, where her work has driven meaningful change. In addition to her impactful research, Professor Nirmala is deeply committed to medical education. As an educator, she inspires undergraduate medical students and postgraduate students to view public health as a transformative discipline that extends beyond illness, fostering solutions that enhance the health and well-being of entire populations. She serves as the Coordinator of the Master of Public Health program at Universiti Malaya, shaping the next generation of public health leaders. Her leadership also led to the development and successful implementation of the Master of Epidemiology program in Universiti Malaya, further demonstrating her dedication to capacity-building in the field.

In terms of location and duration, most activities will be conducted within a local middle school, including classrooms, computer labs, and shared school spaces. The project is anticipated to run for approximately three to six months, covering preparation, implementation, and final reporting. The role of the various stakeholders has also been clearly identified. (Figure 2) 

Epidemiological transition and the changing disease burden

The demographic transition has been accompanied by an epidemiological transition. Data comparing global disease burden in 1990 with Japan's disease burden in 2023 reveals marked differences. In 1990, communicable diseases—including neonatal conditions, lower respiratory infections, diarrhea, measles, and malaria—accounted for roughly half of the total disease burden. Child survival was the central focus of global health, premature death was common across the life course, and non-communicable diseases played a secondary role. Population aging was not yet a defining global phenomenon (Figure 2).

Discussion

Dr. Kawahara asked what the biggest structural barriers to credible survivorship care in Asia are, and how health systems can realistically address them.

Dr. Bhoo-Pathy responded that the biggest problem, in both low- and middle-income countries and in high-income countries, is that government investment in cancer control is heavily directed towards biotechnology and cancer medicines. What is lacking is investment in the human dimension of cancer care. Cancer is not purely a clinical disease; patients need psychosocial support, palliative care, supportive care, and survivorship care so that they can return to society or, for those at end of life, have a dignified death. Health systems do not invest adequately in these areas. She noted that she had led a Lancet Oncology Commission that addressed exactly the questions Dr. Kawahara had raised and directed the audience to that commission report for detailed recommendations on what health systems can do.

A student who had experience of working as an in-hospital healthcare professional and served as a program lead for a WHO-supported package of essential non-communicable disease interventions, asked about the difficulty of conveying the systemic value and cost-benefit of cancer prevention, not only to the public but also to healthcare workers themselves.

Dr. Bhoo-Pathy responded that public health professionals, including herself, have inadvertently reinforced a narrative of cancer as a costly threat. The approach her group is now taking is to reframe cancer control not as an expense but as an investment case. The key is to demonstrate the cost of inaction. Her group had published work in the Journal of the National Cancer Institute examining productivity loss from premature cancer mortality, showing governments how much they stand to save if they invest in cancer control rather than allowing premature deaths to continue. Changing the narrative from negative (cancer is expensive) to positive (investment in cancer control yields returns) is one of the main steps in getting policymakers to take cancer seriously. She noted that the reluctance to engage with cancer because of its perceived cost is an issue that is common to all countries. She encouraged the students to think creatively about how to build investment cases and what kind of evidence is needed to support them.

A student asked about the state of return-to-work pathways in Asian countries, noting uncertainty about whether structured policies exist and raising the issue of workplace bias against cancer patients.

Dr. Bhoo-Pathy responded that the question spans two situations: patients who want to return to the same job after treatment, and those who have lost their jobs and need to find new employment. Both remain problems across much of Asia and in low- and middle-income countries generally. Employment protection policies are often inadequate or non-existent. She introduced the concept of the “right to be forgotten,” a policy principle under which systems would disregard a person’s cancer history and allow them to enter the job market on equal terms with those who have not had cancer. Such policies exist in some high-income countries but are absent in most of the Asia-Pacific region. She referenced qualitative research her group had conducted in Malaysia on the employment needs of cancer survivors, noting that workers in the government sector tend to be more protected from discrimination than those in the private sector. She also noted her involvement in the return-to-work working group of the Multinational Association of Supportive Care in Cancer (MASCC), adding that these issues remain unresolved even in high-income countries. She stressed that building evidence is necessary but not sufficient; findings must be translated into a language that policymakers and the public can act on.

A student asked about the current state of tertiary prevention in Asian countries, observing that it appeared to be at an early stage.

Dr. Bhoo-Pathy confirmed that tertiary prevention in Asia is in its infancy. She cited a report card produced by the Economist Intelligence Unit that compared breast cancer care across selected Asia-Pacific countries, scoring them in areas such as primary prevention, treatment access, and survivorship. In most countries, the lowest score was in survivorship. The pattern is that when health systems allocate funding, treatment receives priority. Governments are now beginning to recognize the need to invest in primary prevention, but awareness that survivorship care also requires investment has not yet taken hold. She and like-minded colleagues across the region are working to build the evidence base and move the agenda forward. As a practical example, she described a patient navigation and financial navigation program she is piloting in Malaysia. The program helps cancer patients navigate the complexities of multiple tests, departments, and hospital visits, and connects them to financial and non-tangible support such as help with transport costs. The goal is not to provide resources directly but to help patients find and access existing resources so they remain in the system. She characterized this as implementation science and encouraged students to pursue training in the field, noting that the upcoming APOCP conference would include an introductory workshop on implementation science.

A student asked how a small school-based pilot project like the one introduced earlier could contribute to broader system-level change rather than remaining an isolated case study.

Dr. Bhoo-Pathy responded that bridging the gap between pilot projects and system-level impact requires understanding the local context. For any health system or locality, it is essential to identify and involve local stakeholders from the outset. If a project is being conducted in a foreign country, the most important step is to ensure that local people are involved from the beginning, creating a sense of shared ownership. Without this, even a well-intentioned project will end when the external team departs and no one will carry it forward. Investment in training local stakeholders to take ownership is therefore critical. Beyond experts and professionals, parents, school committees, and parent-teacher associations should be involved and should see the project as their own.

The same student followed up by asking what ability is most important when connecting with local communities, particularly in a culturally diverse country like Malaysia.

Dr. Bhoo-Pathy answered that cultural humility is essential, namely respecting how things work locally, not imposing oneself, sharing ideas, and being attentive to tone and manner. She noted that Malaysia and Japan are similar in this respect. However, the most important practical step is to establish a local partner as an equal. The project cannot succeed if the external team positions itself as the leader with local people working under its direction. Instead, there should be co-leadership: the external team brings technical and content expertise, while the local partner brings cultural and systems expertise. The endeavor must be shared. She warned against replicating a dynamic in which the project is seen as belonging to the external institution, citing problems that have arisen when researchers from the Global North have conducted projects in Africa without genuine partnership. She also emphasized the importance of transparent conversations about intellectual property ownership from the outset, making clear that the work is co-owned. Finally, she stressed the need for flexibility: if a prototype has been developed, it must be presented to local stakeholders for their input, and if they suggest adaptations, those adaptations must be made.

A student asked how sustainable cancer prevention programs can be in low- and middle-income countries, given that governments tend to focus on treatment and pay less attention to prevention.

Dr. Bhoo-Pathy responded by returning to the productivity-loss argument. Research her group has conducted shows that in countries with greater investment in cancer prevention and control—such as Japan, Korea, and Singapore—there is less premature mortality and, consequently, lower productivity loss as a percentage of GDP. This data is available by country through the Global Cancer Observatory website (https://gco.iarc.fr/en). She noted that she is currently leading a study focused specifically on the ASEAN region, benchmarking productivity losses from premature cancer mortality against Japan and Korea. She reiterated that treatment alone is not enough, because treatment does not automatically result in people returning to work. Good psychosocial and financial support is needed alongside treatment. She also pointed out a difference in cancer demographics: in low- and middle-income countries, cancer more often affects people in their prime working years, whereas in high-income countries it tends to affect older, often retired, populations. This makes the economic impact of cancer on the workforce more acute in the developing world.

A student asked about the gender perspective of cancer care. She observed that in Malaysia and most countries, cancer care for older adults relies heavily on families, particularly women. She questioned whether this model is sustainable given declining fertility rates, migration, and changing gender roles, and asked whether Malaysia has realistic alternatives—particularly in light of Japan’s experience with elderly adults living alone.

Dr. Bhoo-Pathy responded that the question has multiple layers and that answers depend on the health system in question. In Malaysia’s case, health financing comes from general taxation, so the public system provides a safety net, although out-of-pocket spending is a growing problem. On the broader question of women as caregivers, she pointed to research from Africa examining the intergenerational impact on families when mothers die of breast cancer. She then directed students to The Lancet Commission on Women, Power, and Cancer, which she described as addressing many of the issues raised by the student. That commission examines the roles of women as patients, caregivers, and cancer care professionals, and explores how power dynamics intersect with socioeconomic status, ethnicity, ageism, and other forms of discrimination across the cancer continuum. She noted that the commission’s findings apply beyond cancer to any non-communicable disease, and that the evidence comes from around the world, not only from low- and middle-income countries. She added that gender inequity in cancer care is not exclusively about women; men also face barriers, for example in societies where they are reluctant to be examined or screened by healthcare workers of the opposite sex. The issue is gender inequity and power asymmetries more broadly, including the experiences of people who do not fit into conventional gender categories.

Dr. Kawahara closed the session by summarizing the key messages of the lecture. She noted that cancer prevention is not only about awareness or medical technology but about systems, society, the economy, and life after cancer. She highlighted the message that treatment innovation alone cannot address the poverty, inequity, and social loss caused by cancer, and that survivorship represents a new front line in cancer prevention. 

Dr. Kawahara noted that Dr. Bhoo-Pathy’s message to the next generation—to think beyond hospitals, learn the language of policy, work across sectors, and communicate well—perfectly captures the core of this lecture series: “Beyond Boarders: Navigating Health Knowledge for Well-being.” 

Dr. Kawahara noted that the lecture has encouraged students to ask such questions as: What does it mean to connect research to society? How do we communicate evidence and translate it into policy? What responsibility do we carry when we collaborate across Asia?

The lecture had also demonstrated that APOCP is much more than a conference. It is a regional platform for shared learning, real-world implementation, and nurturing the next generation of leaders. 

Dr. Kawahara closed by encouraging students to ask a deeper question of themselves while writing their final assignment: “From which position will I contribute to cancer prevention in Asia?”